| Entity Name: | INTERCOMMUNITY CANCER CENTER - LADY LAKE CAMPUS, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 20 Aug 2001 (23 years ago) |
| Date of dissolution: | 26 Sep 2014 (10 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 26 Sep 2014 (10 years ago) |
| Document Number: | L01000013946 |
| FEI/EIN Number | 593738703 |
| Address: | 301 SOUTH LAKE STREET, LEESBURG, FL, 34748 |
| Mail Address: | 301 SOUTH LAKE STREET, LEESBURG, FL, 34748 |
| ZIP code: | 34748 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1013903699 | 2005-09-20 | 2012-01-30 | PO BOX 863359, ORLANDO, FL, 328863359, US | 922 ROLLING ACRES RD, LADY LAKE, FL, 321595022, US | |||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||
| Phone | +1 352-326-2224 |
| Fax | 3523268335 |
| Phone | +1 352-753-6198 |
Authorized person
| Name | HAL M JACOBSON |
| Role | MEDICAL DIRECTOR |
| Phone | 3523262224 |
Taxonomy
| Taxonomy Code | 2085R0001X - Radiation Oncology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | RR MEDICARE |
| Number | DE8303 |
| State | FL |
| Issuer | MEDICAID |
| Number | 273918600 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SCOTT KENNETH | Agent | 1048 JULIETTE BLVD, MOUNT DORA, FL, 32757 |
| Name | Role | Address |
|---|---|---|
| HAL MARTIN JACOBSON FAMILY TRUST | Manager | 301 SOUTH LAKE STREET, LEESBURG, FL, 34748 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2014-09-26 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2012-03-28 | 301 SOUTH LAKE STREET, LEESBURG, FL 34748 | No data |
| CHANGE OF MAILING ADDRESS | 2012-03-28 | 301 SOUTH LAKE STREET, LEESBURG, FL 34748 | No data |
| REGISTERED AGENT NAME CHANGED | 2007-03-22 | SCOTT, KENNETH | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2007-03-22 | 1048 JULIETTE BLVD, MOUNT DORA, FL 32757 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2013-03-06 |
| ANNUAL REPORT | 2012-03-28 |
| ANNUAL REPORT | 2011-04-14 |
| ANNUAL REPORT | 2010-03-24 |
| ANNUAL REPORT | 2009-03-16 |
| ANNUAL REPORT | 2008-03-31 |
| ANNUAL REPORT | 2007-03-22 |
| ANNUAL REPORT | 2006-05-31 |
| ANNUAL REPORT | 2005-05-04 |
| ANNUAL REPORT | 2004-03-25 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
